California Individual & Family Plans Health Net Life Insurance Company .
California Individual & Family Plans Health Net Life Insurance Company (Health Net) Bronze 60 EnhancedCare PPO Plan Overview Your Provider Network The Bronze 60 EnhancedCare PPO health plan utilizes the EnhancedCare PPO provider network for covered benefits and services. Please make sure you use providers (doctors, hospitals, etc.) in the EnhancedCare PPO provider network. EnhancedCare PPO is available directly through Health Net in Los Angeles, Orange, Sacramento, San Diego, and Yolo counties, and parts of Placer, Riverside and San Bernardino counties. This matrix is intended to be used to help you compare coverage benefits and is a summary only. The policy and Schedule of Benefits should be consulted for a detailed description of coverage benefits and limitations. The copayment amounts listed below are the fees charged to you for covered services you receive. Copayments can be either a fixed dollar amount or a percentage of Health Net’s cost for the service or supply and is agreed to in advance by Health Net and the contracted provider. Fixed dollar copayments are due and payable at the time services are rendered. Percentage copayments (also called coinsurance) are usually billed after the service is received. Benefit description Insured person(s) responsibility In-network1,2 Out-of-network1,3 6,300 single/ 12,600 family 7,000 single/ 14,000 family 12,600 single / 25,200 family 25,000 single / 50,000 family Visits 1–3: 75 (ded. waived) / Visits 4 : 75 (ded. applies)6 0 (deductible waived) Visits 1–3: 105 (ded. waived) / Visits 4 : 105 (ded. applies)6 Visits 1–3: 75 (ded. waived) / Visits 4 : 75 (ded. applies)6 0 (deductible waived) 100%9 40 (deductible waived) 100%9 75 (deductible waived) 50% Unlimited lifetime maximum. Benefits are subject to a deductible unless noted. Plan maximums Calendar year deductible4 Out-of-pocket maximum (includes calendar year deductible)5 Professional services Office visit Teladoc consultation telehealth services7 Specialist consultation Other practitioner office visit (including medically necessary acupuncture) Preventive care services8 X-ray and diagnostic imaging Laboratory procedures Imaging (CT/PET scans, MRIs) Rehabilitation and habilitation therapy Not covered 50% 50% Not covered 50% 50% 50% Not covered Hospital services Inpatient hospital facility services (includes maternity) 100%9 Outpatient surgery (hospital or outpatient surgery center charges only) 100%9 Skilled nursing facility 100%9 Emergency services Emergency room (copayment waived if admitted) Urgent care Ambulance services (ground and air) Mental/Behavioral health / Substance use disorder services10 Mental/Behavioral health / Substance use disorder (inpatient) Mental/Behavioral health / Substance use disorder (outpatient) Home health care services (100 visits/year) 50% 50% 50% 100%9 facility (ded. applies) / 0 physician (ded. waived) Visits 1–3: 75 (ded. waived) / Visits 4 : 75 (ded. applies)6 100%9 100%9 facility (ded. applies) / 0 physician (ded. waived) 50% 100%9 Office visit: 0 (ded. waived) Other than office visit: 100% up to 75 100%9 50% Office visit: 50% Other than office visit: 50% 100%9 Not covered (continued)
Benefit description Other services Durable medical equipment Hospice service Insured person(s) responsibility In-network1,2 Out-of-network1,3 100%9 Not covered 0 (deductible waived) 50% 500 single / 1,000 family Not covered Prescription drug coverage Prescription drug calendar year deductible (per insured) Prescription drugs11 (up to a 30-day supply obtained through a participating pharmacy) Tier I (most generics and low-cost preferred brands) Tier II (non-preferred generics and preferred brands) Tier III (non-preferred brands only) Tier IV (Specialty drugs) 100% up to 500 / 30-day script Not covered (after Rx deductible)12 Diagnostic and preventive services 0 (deductible waived) Not covered 0 (deductible waived) Not covered 1 pair per year – 0 (deductible waived) Not covered Pediatric dental13,14 Pediatric vision13,15 Eye exam Glasses This is a summary of benefits. It does not include all services, limitations or exclusions. Please refer to the policy for terms and conditions of coverage. 1 Certain services require prior certification from Health Net. Without prior certification, an additional 250 is applied for in-network providers and 500 is applied for out-of-network providers. Refer to the policy for details. 2 Insured 3 Please pays the negotiated rate, which is the rate participating or preferred providers have agreed to accept for providing a covered service. refer to the policy for out-of-network reimbursement methodology. 4 Any amount applied toward the calendar year deductible for covered services and supplies received from an in-network provider will not apply toward the calendar year deductible for out-of-network providers. In addition, any amount applied toward the calendar year deductible for covered services and supplies received from an out-of-network provider will not apply toward the calendar year deductible for in-network providers. 5 Copayments or coinsurance paid for in-network services will not apply toward the out-of-pocket maximum for out-of-network providers, and coinsurance paid for out-of-network services will not apply toward the out-of-pocket maximum for preferred providers. Copayments or coinsurance for out-of-network emergency care, including emergency room and ambulance services, accrues to the out-of-pocket maximum for preferred providers. 6 Visits 1–3 (combined between primary care office visits, specialist office visits, urgent care, postnatal visits, and acupuncture): The calendar year deductible is waived. Visits 4–unlimited: The calendar year deductible applies. 7 Health Net contracts with Teladoc to provide telehealth services for medical, mental disorders and chemical dependency conditions. Teladoc services are not intended to replace services from your physician, but are a supplemental service. Telehealth services that are not provided by Teladoc are not covered. In addition, Teladoc consultation services do not cover: specialist services; and prescriptions for substances controlled by the DEA, non-therapeutic drugs or certain other drugs which may be harmful because of potential for abuse. 8 Covered services based on the United States Preventive Services Task Force (USPSTF) grade A and B recommendations; recommendations of the Advisory Committee on Immunization Practices (ACIP) that have been adopted by the Director of the Centers for Disease Control and Prevention (CDC); women’s preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and comprehensive guidelines supported by HRSA for infants, children and adolescents. For more information about generally recommended preventive services, go to www.healthcare.gov. The applicable cost-sharing for preventive care will apply to these services. 9 After the medical deductible has been reached, the member is responsible for 100% of the eligible charges until his or her out-of-pocket maximum limit is met. For in-network benefits, eligible charges are the negotiated rate. For out-of-network emergency room and emergency medical transportation, eligible charges are the allowed charges. 10 B enefits are administered by MHN Services, an affiliate behavioral health administrative services company, which provides behavioral health services. 11 The Essential Rx Drug List is a list of prescription drugs that are covered by this plan. Some drugs require prior authorization from Health Net. For a copy of the Essential Rx Drug List, go to Health Net’s website. Refer to the policy for complete information about prescription drugs. Plans will cover most female prescription contraceptives at 0 cost-share. Coverage on some drugs may not follow the generic and brand tier system. Please refer to your policy and Health Net’s Essential Rx Drug List for coverage, cost-share and tier information. The policy is a legal, binding document. If the information in this brochure differs from the information in the policy, the policy controls. Prescription drugs filled through mail order (up to a 90-day supply) require twice the level of copayment. For details regarding a specific drug, go to www.myhealthnetca.com. 12 After the Pharmacy deductible has been reached, the member will be responsible for 100% of the cost of all Tier 1, 2, 3, and 4 drugs up to a maximum payment of 500 for each prescription of up to a 30-day supply, until the out-of-pocket maximum limit is met. 13 Pediatric dental and vision are included on all plans. 14 The pediatric dental benefits are underwritten by Health Net Life Insurance Company and administered by Dental Benefit Administrative Services. Dental Benefit Administrative Services is not affiliated with Health Net Life Insurance Company. See the policy for pediatric dental benefit details. 15 The pediatric vision services benefits are underwritten by Health Net Life Insurance Company and administered by EyeMed Vision Care, LLC. EyeMed Vision Care, LLC is not affiliated with Health Net Life Insurance Company. Health Net EnhancedCare PPO insurance plans, Policy Form # P35001, are underwritten by Health Net Life Insurance Company. Health Net Life Insurance Company is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All rights reserved. FLY014071EH00 (1/18)
Nondiscrimination Notice Health Net Life Insurance Company (Health Net) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Health Net: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Health Net’s Customer Contact Center at: Group Employer Applicants 1-800-522-0088 (TTY: 711) Individual & Family Plan Applicants 1-877-609-8711 (TTY: 711) If you believe that Health Net has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Health Net’s Customer Contact Center is available to help you. You can also file a grievance by mail, fax or online at: Health Net Life Insurance Company PO Box 10348 Van Nuys, CA 91410-0348 Fax: 1-877-831-6019 Online: healthnet.com You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800-537-7697). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
English No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card, or employer group applicants please call 1-800-522-0088 (TTY: 711). Individual & Family Plan (IFP) applicants please call 1-877-609-8711 (TTY: 711). For more help: If you are enrolled in a PPO or EPO insurance policy from Health Net Life Insurance Company, call the CA Dept. of Insurance at 1-800-927-4357. If you are enrolled in an HMO or HSP plan from Health Net of California, Inc., call the DMHC Helpline at 1-888-HMO-2219. Arabic ، للحصول على المساعدة . ويمكنك الحصول على وثائق مقروءة لك . يمكنك الحصول على مترجم فوري . خدمات اللغة مجانية أو يرجى من مقدمي طلبات مجموعة أصحاب العمل االتصال بمركز االتصال ، اتصل بنا على الرقم الموجود على بطاقة الهوية ) االتصال على الرقم IFP( يرجى من مقدمي طلبات خطة األفراد والعائلة .)TTY: 711( 1-800-522-0088 PPO في حال كنت مسجالً في بوليصة تأمين المنظمة المزودة المفضلة : وللحصول على المساعدة .)TTY: 711( 1-877-609-8711 اتصل على قسم التأمين في كاليفورنيا على الرقم ، Health Net Life Insurance Company من EPO أو المنظمة المزودة الحصرية من شركة HSP أو خطة التوفير الصحية HMO في حال كنت مسجالً في منظمة المحافظة على الصحة .1-800-927-4357 .1-888-HMO-2219. على الرقم DMHC اتصل على خط المساعدة في قسم الرعاية الصحية المدارة , .Health Net of California, Inc Armenian Անվճար լեզվական ծառայություններ: Դուք կարող եք բանավոր թարգմանիչ ստանալ: Փաստաթղթերը կարող են կարդալ ձեզ համար ձեր լեզվով: Օգնության համար զանգահարեք մեզ ձեր ID քարտի վրա նշված հեռախոսահամարով, իսկ գործատուի խմբի դիմորդներին խնդրում ենք զանգահարել 1-800-522-0088 (TTY: 711) հեռախոսահամարով: Անհատական և Ընտանեկան Ծրագրի անգլերեն հապավումը՝ (IFP) դիմորդներին խնդրում ենք զանգահարել 1-877-609-8711 (TTY: 711) հեռախոսահամարով: Լրացուցիչ օգնության համար. եթե անդամագրված եք Health Net Life Insurance Company-ի PPO կամ EPO ապահովագրությանը, զանգահարեք Կալիֆորնիայի Ապահովագրության բաժին՝ 1-800-927-4357 հեռախոսահամարով: Եթե անդամագրված եք Health Net of California, Inc.-ի HMO կամ HSP ծրագրին, զանգահարեք DMHC օգնության գիծ՝ 1-888-HMO-2219 հեռախոսահամարով. Chinese ��，並請我們將有 ��與我們聯絡， 雇主團體申請人請致電 畫 (IFP) 申請人請致電 助：如果您透過 Health Net Life Insurance Company 投保 PPO 或 EPO 保單，請致電 1-800-927-4357 與加州保險局聯絡。如果您透過 Health Net of California, Inc. 投保 HMO 或 HSP 計畫，請致電 DMHC 協助專線 1-888-HMO-2219。 Hindi बिना लागत की भाषा सेवाएँ। आप एक दभ ु ाबषया प्ाप्त कर सकते हैं । आपको दसतावेज अपनी भाषा में पढ़ कर सुनाए जा सकते हैं । मदद के ललए, आपके आईडी काड्ड पर ददए गए सूचीिद्ध नंिर पर हमें कॉल करें , या लनयोक्ा समूह आवेदक कृ पया 1-800-522-0088 (TTY: 711) संपक्ड केंद्र पर कॉल करें । कृ पया वयबक्गत और पाररवाररक पललैन (IFP) के आवेदक 1-877-609-8711 (TTY: 711) पर कॉल करें । अलिक मदद के ललए: यदद आप Health Net Life Insurance Company PPO या ईपीओ EPO िीमा पॉललसी में नामांदकत हैं , तो कलैललफोलन्डया िीमा बवभाग को 1-800-927-4357 पर कॉल करें । यदद आप Health Net of California, Inc., एचएमओ HMO या एचएसपी HSP पललैन में नामांदकत हैं , तो डीएमएचसी DMHC हे लपलाइन के 1-888-HMO-2219 पर कॉल करें । Hmong Kev Pab Txhais Lus Dawb. Koj xav tau neeg txhais lus los tau. Koj xav tau neeg nyeem cov ntaub ntawv kom yog koj hom lus los tau xav tau kev pab, hu peb tau rau ntawm tus xov tooj nyob ntawm koj daim npav, los yog tias koj yog tus neeg tso npe xav tau kev pab kho mob los ntawm koj txoj hauj-lwm thov hu rau 1-800-522-0088 (TTY: 711). Yog koj yog tus tso npe xav tau kev pab kho mob rau Ib Tug Neeg & Tsev Neeg Individual & Family Plan (IFP) thov hu 1-877-609-8711 (TTY: 711). Xav tau kev pab ntxiv: Yog koj tau tsab ntawv tuav pov hwm PPO los yog EPO los ntawm Health Net Life Insurance Company, hu mus rau CA Dept. of Insurance ntawm 1-800-927-4357. Yog koj tau txoj kev pab kho mob HMO los yog HSP los ntawm Health Net of California, Inc., hu mus rau DMHC tus xov tooj pab Helpline ntawm 1-888-HMO-2219. Japanese ��ます。援助が必要な場 �た団体保険の申込者の
of Insurance ntawm 1-800-927-4357. Yog koj tau txoj kev pab kho mob HMO los yog HSP los ntawm Health Net of California, Inc., hu mus rau DMHC tus xov tooj pab Helpline ntawm 1-888-HMO-2219. Japanese ��ます。援助が必要な場 �た団体保険の申込者の 方は、 1-800-522-0088、(TTY: 711) �向けプラン (IFP) の申込者の方は、 1-877-609-8711 (TTY: 711) �要な場合: Health Net Life Insurance ��されている方は、カリフォル ニア州保険局 1-800-927-4357 alth Net of California, Inc.のHMO ��ルプライン 1-888-HMO-2219 まで電話でお問い合わせ ください。 Khmer �្លៃ។ �� �នឯកសារឱ្យអ្នក �្នក។ េ្មាប់ជំនួយ េូ មទាក់ទងសយង លៃ ើ ��តេមាគាល់ខួ នរប េ់អ្នក ឬ សបក្ខជន្ករុមនសិ ោជក នុន 1-800-522-0088 (TTY: 711)។ �សារ �នុគគាល េូ មទូរេពទាសៅសលខ 1-877-609-8711 (TTY: 711)។ � ៖ � �ណ៍ធានារ៉ា ប់រង PPO ឬ EPO Health Net Life Insurance Company េូ មទាក់ទងសៅនា យកោឋានធានារ៉ា ប់រង CA តាមរយៈទូរេពទាសលខ 1-800-927-4357។ សបេ ើ ិ �ក្ននុងបែនការ HMO ឬ HSP ព្ី ករុមហ៊នុន Health Net �ា េូ �ជំនួយ DMHC ៖ 1-888-HMO-2219។ Korean 무료 언어 서비스. 통역 서비스를 받을 수 있습니다. 귀하가 구사하는 언어로 문서의 낭독 서비스를 받으실 수 있습니다. 도움이 필요하시면 보험 ID 카드에 수록된 번호로 전화하시거나 고용주 그룹 신청인의 경우 1-800-522-0088 (TTY: 711) 번으로 전화해 주십시오. Individual & Family Plan (IFP) 신청인의 경우, 1-877-609-8711 (TTY: 711) 번으로 전화해 주십시오. 추가 도움이 필요하시면, Health Net Life Insurance Company의 PPO 또는 EPO 보험에 가입되어 있으시면 캘리포니아 주 보험국에1-800-927-4357번으로 전화해 주십시오. Health Net of California, Inc.의 HMO 또는 HSP 플랜에 가입되어 있으시면 DMHC 도움라인에 1-888-HMO-2219번으로 전화해 주십시오. Navajo Saad Bee !k1 E’eyeed T’11 J77k’e. Ata’ halne’7g77 h0l . T’11 h0 hazaad k’ehj7 naaltsoos hach’8’ w0ltah. Sh7k1 a’doowo[ n7n7zingo naaltsoos bee n47ho’d0lzin7g77 bik1a’gi b44sh bee hane’7 bik11’ 1aj8’ hod77lnih 47 doodaii’ employer group-j7 ninaaltsoos si[tsoozgo 47 1-800-522-0088 (TTY: 711). T’11 h0 d00 ha’1[ch7n7 bi[ hak’4’4sti’7g77 (IFP woly4h7g77) 47 koj8’ hojilnih 1-877-609-8711 (TTY: 711).Sh7k1 an11’doowo[ jin7zingo: PPO 47 doodaii’ EPO-j7 Health Net Life Insurance Company woly4h7j7 b4eso 1ch’33h naa’nil biniiy4 hwe’iina’ bik’4’4sti’go 47 CA Dept. of Insurance bich’8’ hojilnih 1-800-927-4357. HMO 47 doodaii’ HSP-j7 Health Net of California-j7 b4eso 1ch’33h naa’nil biniiy4 hats’77s bik’4’4sti’go 47 koj8’ hojilnih DMHC Helpline 1-888-HMO-2219. Persian (Farsi) . می توانيد درخواست کنيد که اسناد به زبان شما برايتان قرائت شوند . می توانيد يک مترجم شفاهی بگيريد . خدمات زبان به طور رايگان ً يا درخواست کنندگان گروه کارفرما لطفا ، با ما به شماره ای که روی کارت شناسايی شما درج شده تماس بگيريد ، برای دريافت راهنمايی ً ) لطفا IFP( درخواست کنندگان برنامه انفرادی يا خانواده . ) تماس بگيريد TTY: 711( 1-800-522-0088 با مرکز تماس بازرگانی از سوی EPO يا PPO اگر در بيمه نامه : برای دريافت راهنمايی بيشتر . ) تماس بگيريد TTY: 711( 1-877-609-8711 با شماره تماس 1-800-927-4357 به شماره CA Dept. of Insurance با ، عضويت داريد Health Net Life Insurance Company DMHC با خط راهنمايی تلفنی ، عضويت داريد .Health Net of California, Inc از سوی HSP يا HMO اگر در برنامه . بگيريد . تماس بگيريد 1-888-HMO-2219 به شماره Panjabi (Punjabi) ਬਿਨਾਂ ਬਿਸੇ ਲਾਗਤ ਤੋਂ ਭਾਸਾ ਸੇਵਾਵਾਂ। ਤੁਸੀਂ ਇੱਿ ਦੁਭਾਬਸਆ ਪ੍ਾਪਤ ਿਰ ਸਿਦੇ ਹੋ। ਤੁਹਾਨੂੰ ਦਸਤਾਵੇਜ਼ ਤੁਹਾਡੀ ਭਾਸਾ ਬਵੱਚ ਪੜ੍ਹ ਿੇ ਸੁਣਾਏ ਜਾ ਸਿਦੇ ਹਨ। ਮਦਦ ਲਈ, ਆਪਣੇ ਆਈਡੀ ਿਾਰਡ ਤੇ ਬਦੱਤੇ ਨੰਿਰ ਤੇ ਸਾਨੂੰ ਿਾਲ ਿਰੋ ਜਾਂ ਬਿਰਪਾ ਿਰਿੇ 1-800-522-0088 (TTY: 711) ’ਤੇ ਿਾਲ ਿਰੋ। ਬਵਅਿਤੀਗਤ ਅਤੇ ਪਾਬਰਵਾਰਿ ਪਲੈ ਨ (IFP) ਦੇ ਆਵੇਦਿ ਬਿਰਪਾ ਿਰਿੇ 1-877-609-8711 (TTY: 711) ’ਤੇ ਿਾਲ ਿਰੋ। ਵਧੇਰੀ ਮਦਦ ਲਈ: ਜੇ Health Net Life Insurance Company ਤੋਂ ਇੱਿ ਪੀਪੀਓ PPO ਜਾਂ ਈਓਪੋ EPO ਿੀਮਾ ਪਾਬਲਸੀ ਬਵੱਚ ਨਾਮਾਂਬਿਤ ਹੋ, ਤਾਂ ਿੈਲੀਫੋਰਨੀਆਂ ਿੀਮਾ ਬਵਭਾਗ ਨੂੰ 1-800-927-4357 ’ਤੇ ਿਾਲ ਿਰੋ। ਜੇ ਤੁਸੀਂ ਹੈਲਥ ਨੈੱਟ ਆਫ਼ ਿੈਲੀਫ਼ੋਰਨੀਆਂ, ਇੰ ਿ ਤੋਂ ਇੱਿ ਐਚਐਮਓ HMO ਜਾਂ ਐਚਐਸਪੀ HSP ਪਲੈ ਨ ਬਵੱਚ ਨਾਮਾਂਬਿਤ ਹੋ ਤਾਂ ਡੀਐਮਐਚਸੀ DMHC ਹੈਲਪਲਾਈਨ ਨੂੰ 1-888-HMO-2219 ’ਤੇ ਿਾਲ ਿਰੋ। Russian Бесплатная помощь переводчиков. Вы можете получить помощь устного переводчика. Вам могут
’ਤੇ ਿਾਲ ਿਰੋ। ਜੇ ਤੁਸੀਂ ਹੈਲਥ ਨੈੱਟ ਆਫ਼ ਿੈਲੀਫ਼ੋਰਨੀਆਂ, ਇੰ ਿ ਤੋਂ ਇੱਿ ਐਚਐਮਓ HMO ਜਾਂ ਐਚਐਸਪੀ HSP ਪਲੈ ਨ ਬਵੱਚ ਨਾਮਾਂਬਿਤ ਹੋ ਤਾਂ ਡੀਐਮਐਚਸੀ DMHC ਹੈਲਪਲਾਈਨ ਨੂੰ 1-888-HMO-2219 ’ਤੇ ਿਾਲ ਿਰੋ। Russian Бесплатная помощь переводчиков. Вы можете получить помощь устного переводчика. Вам могут прочитать документы в переводе на ваш родной язык. За помощью обращайтесь к нам по телефону, приведенному на вашей идентификационной карточке участника плана. Если вы хотите стать участником группового плана, предоставляемого работодателем, звоните в коммерческий контактный центр компании 1-800-522-0088 (TTY: 711). Если вы хотите стать участником плана для семей и частных лиц (IFP), звоните по телефону 1-877-609-8711 (TTY: 711). Дополнительная помощь: Если вы включены в полис PPO или EPO от страховой компании Health Net Life Insurance Company, звоните в Департамент страхования штата Калифорния CA Dept. of Insurance, телефон 1-800-927-4357. Если вы включены в план HMO или HSP от страховой компании Health Net of California, Inc., звоните по контактной линии Департамента управляемого медицинского обслуживания (DMHC), телефон 1-888-HMO-2219. Spanish Thai Servicios Puede solicitar un intérprete. Puede obtener el servicio de ส lectura de วยเหลือ ไม่มคี า่ บริกde ารด้idiomas านภาษาsin คุณcosto. สามารถใช้ ลา่ มได้ คุณสามารถให้ อา่ นเอกสารให้ ฟงั เป็ นภาษาของคุ ณได้ าหรับความช่ documentos y recibir algunos en su idioma. Para obtener ayuda, llámenos al número que figura en su tarjeta �ขที ใ่ ห้ไว้บนบัตรประจ าตัวของคุ หรือ ผูส้ มัคdeben รกลุม่ นายจ้ างalกรุ1-800-522-0088 ณาโทรหาศูนย์ตดิ ต่(TTY: อเชิงพาณิ ชย์Los ของ de identificación. Los solicitantes del grupo del ณ empleador llamar 711). solicitantes de planes individuales y familiares deben llamar al 1-877-609-8711 (TTY:กรุ711). 1-800-522-0088 (TTY: 711) ผูส้ มัครแผนบุ คคลและครอบครั ว Individual & Family Plan (IFP) ณาโทรPara obtener más ayuda, haga lo siguiente: Si está inscrito en una póliza de seguro PPO o EPO de Health 1-877-609-8711 (TTY: 711) ส �อเพิม่ เติม หากคุณสมัครท �ย Net PPOLife หรือInsurance EPO กับ Company, llame al Departamento de Seguros de California, al 1-800-927-4357. Si está inscrito en un plan Health oNet LifedeInsurance Company โทรหากรมการประกั รัฐแคลิde ฟอร์ เนียได้del ท่ี 1-800-927-4357 หากคุ ณสมัครแผน HMO HSP Health Net of California, Inc., llame น a ภั laยlínea ayuda Departamento de Atención Médica Administrada, HMO หรือ HSP alกับ1-888-HMO-2219. Health Net of California, Inc. �่วยเหลือของ DMHC ได้ท่ี 1-888-HMO-2219. Tagalog Vietnamese Walang Bayad na Mga Serbisyo sa Wika. kayo ng dịch isangviên. interpreter. kayo ngđọc mgacho Các Dị̣ch Vụ Ngôn Ngữ Miễn Phí. Quý vịMakakakuha có thể có một phiên Quý vị Makakakuha có thể yêu cầu được dokumento na babasahin sa inyo sa inyong wika. Para sa tulong, tawagan kami sa nakalistang numero sa inyong nghe tài liệu bằng ngôn ngữ của quý vị. Để nhận trợ giúp, hãy gọi cho chúng tôi theo số được liệt kê trên thẻ ID card, o para sa grupo ng mga aplikante ng employer, mangyaring tawagan ang 1-800-522-0088 (TTY: 711). ID của quý vị, hoặc người nộp đơn vào chương trình theo nhóm của chủ sử dụng lao động vui lòng gọi Para sa mga aplikante ng Plano para sa Indibiduwal at Pamilya Individual & Family Plan, (IFP), mangyaring 1-800-522-0088 (TTY: 711). Người Chương Nhânnakatala & Gia Đình tắt trong policy tiếng tawagan ang 1-877-609-8711 (TTY: nộp 711).đơn Parathuộc sa higit pang Trình tulong:CáKung kayo viết sa insurance Anh là (IFP) vui lòng gọi số 1-877-609-8711 (TTY: 711). Để nhận thêm trợ giúp: Nếu quý vị đăng ký ng PPO o EPO mula sa Health Net Life Insurance Company, tawagan ang CA Dept. of Insurance sa hợp 1-800-927-4357. Kung nakatala sa HMO o HSP na planCompany, mula sa Health Netgọi of Sở California, đồng bảo hiểm PPO hoặc EPO từkayo Health Net Life Insurance vui lòng Y Tế CAInc., theotawagan số ang Helpline ng DMHC savị 1-888-HMO-2219. 1-800-927-4357. Nếu quý đăng ký vào chương trình HMO hoặc HSP từ Health Net of California, Inc., vui lòng gọi Đường Dây Trợ Giúp DMHC theo số 1-888-HMO-2219. Thai ไม่มคี า่ บริการด้านภาษา คุณสามารถใช้ลา่ มได้ คุณสามารถให้อา่ นเอกสารให้ฟงั เป็ นภาษาของคุณได้ ส �อ �ขทีใ่ ห้ไว้บนบัตรประจ าตัวของคุณ หรือ ผูส้ มัครกลุม่ นายจ้าง �ิ � 1-800-522-0088 (TTY: 711) ผูส้ �อบครัว Individual & Family Plan (IFP) กรุณาโทร 1-877-609-8711 (TTY: 711) ส �อเพิม่ เติม หากคุณสมัครท �ย PPO หรือ EPO กับ Health Net Life Insurance Company ��ยได้ท่ี 1-800-927-4357 หากคุณสมัครแผน HMO หรือ HSP กับ Health Net of California, Inc. �่วยเหลือของ DMHC ได้ท่ี 1-888-HMO-2219. Vietnamese Các Dị̣ch Vụ Ngôn Ngữ Miễn Phí. Quý vị có thể có một phiên dịch viên. Quý vị có thể yêu cầu được đọc cho nghe tài liệu bằng ngôn ngữ của quý vị. Để nhận trợ giúp, hãy gọi cho chúng tôi theo số được liệt kê trên thẻ ID của quý vị, hoặc người nộp đơn vào chương trình theo nhóm của chủ sử dụng lao động vui lòng gọi 1-800-522-0088 (TTY: 711). Người nộp đơn thuộc Chương Trình Cá Nhân & Gia Đình viết tắt trong tiếng Anh là (IFP) vui lòng gọi số 1-877-609-8711 (TTY: 711). Để nhận thêm trợ giúp: Nếu quý vị đăng ký hợp đồng bảo hiểm PPO hoặc EPO từ Health Net Life Insurance Company, vui lòng gọi Sở Y Tế CA theo số 1-800-927-4357. Nếu quý vị đăng ký vào chương trình HMO hoặc HSP từ Health Net of California, Inc., vui lòng gọi Đường Dây Trợ Giúp DMHC theo số 1-888-HMO-2219. CA Commercial Applicant Notice of Language Assistance FLY007791EL00 (06/16)
Mental/Behavioral health / Substance use disorder (outpatient) Office visit: 0 (ded. waived) Other than office visit: 100% up to 75 Office visit: 50% Other than office visit: 50% Home health care services (100 visits/year) 100%9 Not covered California Individual & Family Plans Health Net Life Insurance Company (Health Net)
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Covered California amil Dental Plans and Rates for 2021 2 About Covered California’s Family Dental Plans California families now have expanded opportunities for improved dental health through Covered California’s offerings of family dental plans . The plans o